"Medicine is a social science, and politics is nothing else but medicine on a large scale"—Rudolf Virchow

August 09, 2017

Background: The study of regions with high prevalence of centenarians is motivated by a desire to find determinants of healthy ageing. While existing research has focused on selected candidate geographical regions, we explore the existence of hotspots in the whole of Denmark, which is a small and homogeneous country.

Methods: We performed a Kulldorff spatial scan across the whole of Denmark, searching for regions of birth, and regions of residence at age 71, where a significantly increased percentage of the cohort born 1906-1915 became centenarians. Next we compared mortality hazards for the identified regions to the rest of the country by sex and residence at age 71.

Results: We found a birth hotspot of 222 centenarians, 1.37 times more than the expected number, centered on a group of fairly remote rural islands. Significantly lower mortality hazards from age 71 onwards were confined to those who were born within the hotspot and persisted over a period of at least 30 years. At age 71, we found two residence-based hotspots of respectively 348 and 238 centenarians, equaling 1.46- and 1.44 times the expected number. One is located in the high-income suburbs of the Danish capital and here the lower mortality hazard was confined to those who moved into the hotspot. In the second residence-based hotspot, both those who were born, and those who moved into the hotspot, showed significant lower mortality hazards.

Conclusion: Within the whole of Denmark, we identified several centenarian hotspots that have different biological underpinnings. These outcomes point to complex gene-environmental interactions explaining a variety of longevity trajectories.

August 06, 2017

Yemen is currently facing the world’s worst cholera outbreak, which in the span of three months, has spread to the entire country except for one governorate. This is turning an already dire humanitarian situation into a disaster for the conflict-affected population, including women and men, girls and boys.

As of 1 August, WHO reports a cumulative 443,166 suspected cholera cases and 1,921 associated deaths. Cholera is affecting the most vulnerable of Yemenis: children under the age of 15 account for 41% of suspected cases and a quarter of the deaths while those aged over 60 represent 30% of fatalities. Malnourished children, pregnant women and people living with other chronic health conditions are now at greater risk of death.

A WASH and Health-led integrated cholera response plan was finalized and endorsed by the humanitarian community, which has since been elevated to a system-wide response in July 2017.

Not only are the vulnerable at greater risk of death from cholera, but those with specific needs may also face serious challenges if the cholera response is not delivered in a protection-sensitive manner, as well as the fact that cholera may have consequences on households that result in additional protection concerns.

For example, children are not only at risk of becoming separated from their families either due to death of their parents or lack of care arrangements during treatment, but are equally exposed to the psychosocial effects of witnessing their parents dying or undergoing treatment. The domestic roles of women and girls in taking care of sick family members, cleaning latrines, fetching and handling untreated water, and preparing food, means that women and girls are at heightened risk.

Behavior change campaigns at the community level have been undertaken in the affected communities but require significant time. Cholera awareness materials and treatment facilities may not be accessible for persons with disabilities, including those without visible impairments.

Adding the hardship of cholera to household coping mechanisms that are overstretched may expose women and children to risks of abuse and exploitation, and recourse to negative coping mechanisms such as child marriage, recruitment into hazardous forms of labor and family separation. With some 53% of reported cholera cases being women, the long term impact on child care and psychosocial wellbeing in most communities will be enormous.

July 29, 2017

Rising mortality rates, an increase in life-threatening infections and a shortage of staff and medical equipment are crippling Greece’s health system as the country’s dogged pursuit of austerity hammers the weakest in society.

Data and anecdote, backed up by doctors and trade unions, suggest the EU’s most chaotic state is in the midst of a public health meltdown. “In the name of tough fiscal targets, people who might otherwise survive are dying,” said Michalis Giannakos who heads the Panhellenic Federation of Public Hospital Employees. “Our hospitals have become danger zones.”

Figures released by the European Centre for Disease Prevention and Control recently revealed that about 10% of patients in Greece were at risk of developing potentially fatal hospital infections, with an estimated 3,000 deaths attributed to them.

The occurrence rate was dramatically higher in intensive care units and neonatal wards, the body said. Although the data referred to outbreaks between 2011 and 2012 – the last official figures available – Giannakos said the problem had only got worse.

Like other medics who have worked in the Greek national health system since its establishment in 1983, the union chief blamed lack of personnel, inadequate sanitation and absence of cleaning products for the problems. Cutbacks had been exacerbated by overuse of antibiotics, he said.

“For every 40 patients there is just one nurse,” he said, mentioning the case of an otherwise healthy woman who died last month after a routine leg operation in a public hospital on Zakynthos. “Cuts are such that even in intensive care units we have lost 150 beds.”

“Frequently, patients are placed on beds that have not been disinfected. Staff are so overworked they don’t have time to wash their hands and often there is no antiseptic soap anyway.”

No other sector has been affected to the same extent by Greece’s economic crisis. Bloated, profligate and corrupt, for many healthcare was indicative of all that was wrong with the country and, as such, badly in need of reform.

Acknowledging the shortfalls, the government announced last month that it planned to appoint more than 8,000 doctors and nurses in 2017.

Since 2009, per capita spending on public health has been cut by nearly a third – more than €5bn (£4.3bn) – according to the Organisation for Economic Co-operation and Development. By 2014, public expenditure had fallen to 4.7% of GDP, from a pre-crisis high of 9.9%. More than 25,000 staff have been laid off, with supplies so scarce that hospitals often run out of medicines, gloves, gauze and sheets.

In early December Giannakos, a nurse by training, led a protest march, which started at the grimy building housing the health ministry and ended outside the neoclassical office of the prime minister, Alexis Tsipras. At the ministry, hospital technicians erected a breeze-block wall and from it hung a placard with the words: “The ministry has moved to Brussels.”

Doesn't this sound like, oh, Haiti, or Venezuela, or Guinea? I still find it hard to grasp what goes on in the minds of politicians who endorse policy that they must know will kill their own people.

July 18, 2017

A century of research has shown that economic inequality is disastrous for public health: where the gap between rich and poor is wide, the poor live shorter, less healthy lives than the rich. Less well known is the fact that even political events like elections can affect people’s health — especially when the outcome of an election makes them feel marginalized and threatened.

This was brought out in a recent article in the New England Journal of Medicine. Authors David R. Williams and Morgan M. Medlock point out that “Campaigns that give voice to the disenfranchised have been found to have positive but short-term effects on health.” They cite the impact of Nelson Mandela’s 1994 election on black South Africans’ health, and of Barack Obama’s 2008 nomination and campaign for the presidency on the health of Hispanic and black Americans.

“Thus,” the authors conclude, “increases in psychological well-being, pride, and hope for the future are likely to be evident among Donald Trump supporters.”

But for those who feel threatened by Trump’s tweets and promises, serious health issues are likely to persist. Williams and Medlock warn that “The presidential candidacy of Donald Trump appeared to bring further to the surface preexisting hostile attitudes toward racial and ethnic minorities, immigrants, and Muslims.” They cite posts on Daily Stormer saying: “We want these people to feel unwanted. We want them to feel everything around them is against them. And we want them to be afraid.”

Meanwhile, “the Southern Poverty Law Centre has documented an increase in incidents of harassment and hateful intimidation since Trump’s election.”

Such incidents don’t just upset those they’re aimed at. They actually change people’s body chemistry: “incidents of racial discrimination experienced by teenagers predicted flatter diurnal cortisol slopes and lower cortisol awakening response in young adulthood, elevated levels of endocrine, cardiovascular, and metabolic parameters at age 20, as well as epigenetic patterns of aging at age 22.”

Cortisol is an adrenal hormone, produced in response to stress. It reduces inflammation but weakens the immune system, reduces bone formation, and slows the healing of wounds. So the poor predictably suffer more stress, produce more cortisol, get sick, recover slowly, and often self-medicate with everything from booze to opioids to violence. They die much sooner than the rich.

And these are the conditions of the poor under “liberal” governments that oppose religious and racial discrimination and pay lip service to equality. Under reactionary regimes, the poor suffer even more.

July 15, 2017

In the late 1960s, a team of researchers began doling out a nutritional supplement to families with young children in rural Guatemala. They were testing the assumption that providing enough protein in the first few years of life would reduce the incidence of stunted growth.

It did. Children who got supplements grew 1 to 2 centimetres taller than those in a control group. But the benefits didn't stop there. The children who received added nutrition went on to score higher on reading and knowledge tests as adolescents, and when researchers returned in the early 2000s, women who had received the supplements in the first three years of life completed more years of schooling and men had higher incomes.

“Had there not been these follow-ups, this study probably would have been largely forgotten,” says Reynaldo Martorell, a specialist in maternal and child nutrition at Emory University in Atlanta, Georgia, who led the follow-up studies. Instead, he says, the findings made financial institutions such as the World Bank think of early nutritional interventions as long-term investments in human health.

Since the Guatemalan research, studies around the world — in Brazil, Peru, Jamaica, the Philippines, Kenya and Zimbabwe — have all associated poor or stunted growth in young children with lower cognitive test scores and worse school achievement.

A picture slowly emerged that being too short early in life is a sign of adverse conditions — such as poor diet and regular bouts of diarrhoeal disease — and a predictor for intellectual deficits and mortality. But not all stunted growth, which affects an estimated 160 million children worldwide, is connected with these bad outcomes. Now, researchers are trying to untangle the links between growth and neurological development. Is bad nutrition alone the culprit? What about emotional neglect, infectious disease or other challenges?

Shahria Hafiz Kakon is at the front line trying to answer these questions in the slums of Dhaka, Bangladesh, where about 40% of children have stunted growth by the age of two. As a medical officer at the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) in Dhaka, she is leading the first-ever brain-imaging study of children with stunted growth. “It is a very new idea in Bangladesh to do brain-imaging studies,” says Kakon.

The research is innovative in other respects, too. Funded by the Bill & Melinda Gates Foundation in Seattle, Washington, it is one of the first studies to look at how the brains of babies and toddlers in the developing world respond to adversity. And it promises to provide important baseline information about early childhood development and cognitive performance.

Kakon and her colleagues have run magnetic resonance imaging (MRI) tests on two- and three-month-old children, and identified brain regions that are smaller in children with stunted growth than in others. They are also using other tests, such as electroencephalography (EEG).

“Brain imaging could potentially be really helpful” as a way to see what is going on in the brains of these young children, says Benjamin Crookston, a health scientist at Brigham Young University in Provo, Utah, who led studies in Peru and other low-income countries that reported a link between poor growth and cognitive setbacks.

July 12, 2017

The calls began just after midnight and continued relentlessly throughout the day. By the end of Wednesday 26 April, paramedics in the Canadian province of British Columbia had responded to a record 130 suspected overdose calls.

The day offered a window on the battle playing out in British Columbia as residents grapple with an opioid crisis that has claimed, on average, four lives a day in the province.

The struggle is playing out across North America, as authorities in Canada and the US grapple with an epidemic that has claimed thousands of lives on both sides of the 49th parallel.

Against this stark backdrop, a professor at the University of British Columbia has highlighted a different statistic from the crisis: in 2016, of the 935 fatal overdoses in the province, 80% were men.

Research that shows men are more likely to use illicit drugs, so it is perhaps logical that they are more likely to overdose. But the clinical psychologist Dan Bilsker argues that the figure suggests a relationship between the crisis and masculinity – one that may offer clues as to why the death toll continues to rise, and where the solutions might lie.

“I think we haven’t really thought deeply or well about who men are, about what the pressures on them are, what we need them to be,” he said.

Bilsker has spent years studying men’s psychological health, delving into why men live an average of four to six years less than women and are more likely to kill themselves. In some ways, the opioid crisis stems from the same tangled roots, he said. And as with many other health issues, its singular interaction with gender has been largely overlooked.

Across Canada, at least 2,458 people died last year of an opioid overdose, according to the federal government. “The death toll is worse than any other infectious epidemic in Canada, including the peak of Aids deaths, since the Spanish flu that took the lives of 50,000 people a century ago,” Jane Philpott, Canada’s health minister, told a conference in Montreal earlier this year. (Her government has been criticised for not doing enough to address the crisis – as she spoke, protesters unfurled a banner reading: “They talk, we die.”)

Bilsker believes the government’s response would be different if those dying were 80% women. “I suspect there would be more groups – more people actively involved in raising public awareness – who would speak up and engender a greater sense of this being an important issue,” he said.

The gender divide in deaths reflects levels of drug abuse in the province, where 80% of users are men, said Patricia Daly, the chief medical health officer of Vancouver Coastal Health.

“People here often talk about men’s health,” she said. “We don’t have a focus on things that men are at greater risk for and this is certainly one – dying of an overdose is primarily affecting men, and men in the prime of their life.”

July 06, 2017

Nationalism, protectionism and attitudes of "my country first" pose threats to the United Nation's global goals, said a report on Thursday that showed the United States, Russia and China lagging in efforts to meet the ambitious agenda for 2030.

Scandinavian countries are leading the way among 157 nations ranked by the Sustainable Development Solutions Network (SDSN) and Bertelsmann Stiftung, a German social responsibility foundation.

But income inequality, high consumption levels and carbon emissions put the United States at No. 42 in the list while Russia was ranked 62nd and China 71st.

The Sustainable Development Goals, or SDGs, were approved in September 2015 by the 193 U.N. members as a roadmap to tackle the world's most troubling problems by 2030.

The 17 goals, and their accompanying 169 targets, range from halting deforestation to raising living standards, reducing child mortality and promoting global peace. The cost of their enactment has been estimated at $3 trillion a year.

The SDSN, a U.N.-connected group that promotes the SDGs, said the world's most powerful nations are failing to lead the way.

"A rising 'my country first' approach by many heads of government threatens the realization of the SDGs," it said in a statement released with the report.

"Not only does a rising trend of nationalism and protectionism impede the implementation of the goals, but as the report shows, industrialized countries are not serving as role models," it said. "Many of the richest countries in the world are nowhere near achieving the global policy objectives."

Using extensive data and information submitted by nations, the report noted so-called spillovers have a major impact on measuring progress among nations.

For example pollution caused in one nation can harm water quality in another or weapons production in one nation affects peace and security elsewhere.

At the top of the list were Sweden, Denmark, Finland and Norway, with Germany and France also in the top ten. Britain was 16th and Canada 17th.

June 30, 2017

Perhaps in a nod to pleas for a reform less “mean” than the AHCA, the Senate bill would phase down federal funding for the ACA’s Medicaid expansion more slowly than House Republicans proposed to do — but it would impose the same cuts in the long run, and it would implement an even more draconian version of the House’s proposal to cap federal Medicaid funding per enrollee or turn the program into block grants.

All told, the bill would cut more than $700 billion from the program over the next decade. The poorest Americans, those requiring nursing home care, and those with disabilities or mental illness would suffer. These attacks on Medicaid would undercut health care for the 74 million Americans who rely on it.

Women’s health care would also suffer major blows under the BCRA. In states that chose to stop mandating coverage of maternity care, women of child-bearing age could be forced to pay unaffordably high rates for basic pregnancy coverage. Planned Parenthood would be defunded for a year, severely restricting access not just to family planning services but to an array of important preventive care services, including cancer screenings, for millions of low-income women. Another provision would prohibit the use of tax credits for any individual insurance plan that covered abortion services (with exceptions for rape, incest, and risk to the woman’s life).

And at a time when about 60,000 Americans are dying each year from opioid overdoses, the Senate bill would drastically reduce the funds available for confronting this massive crisis and providing affected people the help they need to become functioning, contributing members of society.

In addition to removing many people with opioid use disorder from the Medicaid or individual-insurance rolls, the BCRA would provide a mere $2 billion over 10 years for efforts that experts estimate would cost $183 billion.

The public response to the very similar House bill indicates that the GOP’s approach to health care reform is deeply unpopular throughout the country, with an approval rating below 20%5 — and for good reason. Like many U.S. physician and hospital organizations that are speaking out against the BCRA, we whole-heartedly oppose sacrificing Americans’ health care and health to further enrichment of the wealthy. The future of our health care system and the lives of our patients are at stake.

Meanwhile, this morning Donald Trump is calling on the Senate to repeal Obamacare now and create a new health law later.

Southern Alberta is seeing a surge of cases of pertussis, or whooping cough, and a health official says it's directly related to low immunization rates in some areas.

As of Thursday morning, 38 cases in the Lethbridge area have been linked.

"We are getting multiple lab reports a day and we are definitely seeing this outbreak taking off at an exponential rate," Vivien Suttorp, Alberta Health Services' lead medical officer of health for the south zone, told CBC News.

"We have had a lot of individuals and children exposed to cases of whooping cough and we have a lot of individuals who are not immunized at all."

Suttorp warns those are just the confirmed cases and that whooping cough can often go unreported.

"Individuals who have an ongoing cough for two or three months may not know that they have whooping cough because symptoms can be mild in adults and older children. It's the very young ones that are mostly likely to come to a physician's attention," Suttorp explained.

"There are many, many more out there that we are not aware of."

Immunization rates in southern Alberta can vary significantly.

The Fort Macleod area, for example, ranks nearly dead last out of 132 local health zones in Alberta, but the neighbouring community of Pincher Creek — immediately to the west — ranks among the highest.

The name of one particular church — the Netherlands Reformed Congregation — often comes up when talking about vaccination rates in the Fort Macleod area.

Three years ago I published a Tyee article about a measles outbreak in our own Fraser Valley that was quickly traced to a Dutch Reformed private school. This made it politically dicey: the Fraser Valley is solid right-wing, full of strong supporters of our right-wing provincial government.

While such folks are cautious about newfangled vaccines, they're fans of air travel. The measles outbreak was a direct result of a visit from the Netherlands. A similar visit in 1978 brought British Columbia what I believe was its last polio case.

It beats me why religious groups think God disapproves of vaccines, when He endowed us with both immune systems and brains to strengthen those systems. We're the ones who are supposed to have dominion over the earth, not a bunch of viruses.

The starkest marker of lack of hope in the US is a significant increase in premature mortality in the past decade – driven by an increase in suicides and drug and alcohol poisoning and a stalling of progress against heart disease and lung cancer – primarily but not only among middle-aged uneducated white people. Mortality rates for black and Hispanic people, while higher on average than those for whites, continued to fall during the same time period.

The reasons for this trend are multi-faceted. One is the coincidence of an all-too-readily-available supply of drugs such as opioids, heroin and fentanyl, with the shrinking of blue-collar jobs – and identities - primarily due to technological change. Fifteen per cent of prime age males are out of the labour force today; with that figure projected to increase to 25% by 2050. The identity of the blue-collar worker seems to be stronger for white people than for minorities, meanwhile. While there are now increased employment opportunities in services such as health, white males are far less likely to take them up than are their minority counterparts.

Lack of hope also contributes to rising mortality rates, as evidenced in my latest research with Sergio Pinto. On average, individuals with lower optimism for the future are more likely to live in metropolitan statistical areas (MSAs) with higher mortality rates for 45- to 54-year-olds.

Desperate people are more likely to die prematurely, but living with a lot of premature death can also erode hope. Higher average levels of optimism in metropolitan areas are also associated with lower premature mortality rates. These same places tend to be more racially diverse, healthier (as gauged by fewer respondents who smoke and more who exercise), and more likely to be urban and economically vibrant.

Technology-driven growth is not unique to the US, and low-skilled workers face challenges in many OECD countries. Yet by contrast, away from the US, they have not had a similar increase in premature mortality. One reason may be stronger social welfare systems – and stronger norms of collective social responsibility for those who fall behind – in Europe.